Roger P. Smith

LOWER GASTROINTESTINAL DISEASE IN WOMEN

Gastrointestinal disease is common in women and therefore a commonly encountered entity in gynecologic practice. A new understanding of the underlying pathophysiology of the most common condition, irritable bowel syndrome, is changing both diagnosis and therapy.

Burnout in Obstetricians and Gynecologists

It is estimated that 40% to 75% of obstetricians and gynecologists currently suffer from professional burnout, making the lifetime risk a virtual certainty. Although these statistics make for a dismal view of the profession, if the causes and symptoms can be identified simple steps can be implemented to reverse the threat. With a little care, the enjoyment of practice can be restored and the sense of reward and the value of service can be returned.

The Clinical Classification and Causes of Menorrhagia

While harder to define, document, or diagnose, heavy menstrual bleeding still represents a significant cause of concern, imposition, and morbidity. As noted in Chap. 2, much of this occurs at a stage of life where its impact on education, productivity, or family relationships can have lifelong consequences. It is for this reason that The American College of Obstetricians and Gynecologists and others have recommended that menstruation be viewed as a “vital sign” [1].

Management Strategies for Primary Menorrhagia

Unlike primary dysmenorrhea, the managements of primary and secondary menorrhagia are often intertwined and complicated by the prevalence of difficult-to-identify secondary causes. When true primary menorrhagia is encountered, the same prostaglandin reduction strategies that work so well in primary dysmenorrhea work well for heavy menstrual bleeding. They also work well for many forms of secondary menorrhagia, raising the possibility that underlying pathologies may be missed if a careful assessment is not carried out before treatment, with equally careful monitoring after initiation. Treatment without such evaluation and care may miss symptoms of an easily corrected condition or neoplastic disease.

The Clinical Classification and Causes of Dysmenorrhea

Unlike many conditions in medicine, the classification of painful menstruation into primary and secondary dysmenorrhea is not based on the temporal appearance of symptoms or the condition, as it is in primary and secondary amenorrhea, or primary and secondary infertility. The taxonomy of primary and secondary dysmenorrhea is based upon the absence or presence (respectively) of clinically identifiable causes. In both cases, a great deal is known about the pathophysiology underlying the development of menstrual pain. It is, therefore, not an issue of a lack of identifiable causation; it is the lack of clinically identifiable processes that drive the assignment.

The Inhibition of Prostaglandin Formation

The primary therapeutic modality for patients with primary dysmenorrhea and heavy menstrual bleeding is the nonsteroidal anti-inflammatory drugs (NSAIDs). These agents act primarily to block the formation of the prostaglandins responsible for the symptoms. As noted in the previous chapter, the two prostaglandins responsible, PGE2 and PGF2α, are both made from arachidonic acid through the enzymatic action of cyclooxygenases. Found in two main isoforms, COX-1 and COX-2, the characteristics of these two enzymes allow for specific and effective inhibition of their function. Understanding how this occurs, and the differences between agents that inhibit these enzymes, allows the clinician to better understand and choose effective therapy.

Scope of the Problems

Pain, whether acute, chronic, or recurring, is a major source of morbidity and disability, costing uncounted billions of dollars annually in both direct and indirect costs. The diagnosis and treatment of pain have taken on increased importance in recent years and are now identified as a “vital sign” by the Joint Commission on Accreditation Healthcare Organizations (JCAHO). The treatment of both acute and chronic pain with opiate pain relievers has led to a national crisis over opiate abuse and dependence. For women, pelvic pain is by far the most common type of pain complaint for which treatment is sought. The cyclic pain of dysmenorrhea has been estimated to affect up to 80% of women at some point in their life, with 50% or more experiencing it on a regular basis. Without access to effective treatments, this scope of incapacity should be intolerable to any developed society.

The Physiology of Menstruation

Only humans, closely related primates, some species of bats, and elephant shrews visibly menstruate. The processes that drive the monthly maturation, slough, and renewal of the endometrium that results in menses are ultimately orchestrated by a complex interaction of hormones, tissues, and molecular signaling, all designed to ensure the possibility of securing a pregnancy should a timely mating occur. Menstrual pain and excessive menstrual bleeding are both extremes of a normal continuum. Understanding their development requires a familiarity with the processes that create the normal menstrual cycle. This discussion will focus primarily on the uterus, leaving many of nuances of the complex interactions of the hypothalamus, pituitary, and ovary to others.

How Our Views Have Evolved: Historical Perspectives

Menstruation has been treated as everything from an ordinary event to evidence of a “curse.” Menstruating women have been treated as unclean, shunned, exiled, or ridiculed. It was well known that the touch of a menstruating woman would cause baking bread to fall, flowers to wilt, and brass to tarnish. During her period, a Muslim woman is not allowed inside a Mosque and cannot pray or fast during Ramadan. Even the Bible notes that whenever a woman has her menstrual period, she and those who touch her are “ceremonially unclean” for up to 7 days (Leviticus 15:19–33). This is their lot to deal with, preferably well away from the eyes of a male-dominated society. (The word “taboo” itself comes from the Polynesian word tapua which means “menstruation.”) When strong opiate analgesics failed to control the pain of menstrual cramps, it was easier to attribute the disability to being “all in the head” than to admit to a lack of understanding about the underlying pathophysiology. Ironically, some of these vary myths have led to today’s understanding of dysmenorrhea and menorrhagia and have made it possible for us to talk about prevention rather than relief. Indeed, the success of moving from symptoms to pathophysiology, from amelioration to prevention in dysmenorrhea, paved the way for similar efforts in conditions ranging from interstitial cystitis to migraine headaches. Understanding that journey provides valuable perspectives when we deal with patients who still suffer from these conditions.

Management Strategies for Primary Dysmenorrhea

In 1910, Dr. P. Brooke Bland wrote, “Dysmenorrhea should never be regarded as a morbid process, but should always be looked upon as a manifestation of some systemic or local pelvic condition. It is unfortunate that many women are operated upon for dysmenorrhea without the cause first being determined” [1]. In the past, therapies used to treat dysmenorrhea have ranged from the plausible and somewhat effective, to the outlandish and useless. Everything from cauterizing the middle turbinate of the nose [2], exercise programs [3], and presacral sympathectomy [4, 5] to uterine relaxing factor [6], vasodilators [7, 8], tranquilizers [9], and hormones [10, 11] have been recommended to relieve dysmenorrhea. The use of electric current has even been advocated [12], employing an insulated chair, an intravaginal electrode, and a spark gap high-voltage generator. This treatment was to be administered for 20 min daily over a 4-week period. The treatment was reported to have had good effects, possibly do to a low return rate of patients treated in this way.